The 20:20 vision
The 20:20 Vision is a coherent set of connected ideas to improve the delivery of healthcare through
better risk and process management. The aim is to deliver a combination of extra services and
savings in the form of an extra million QALYs a year (at £20,000/QALY, which is at the affordable end
the of NICE feasibility criterion) and saving 20% of the current budget – £20 billion – per annum. An
outline of the ideas, is shown in the first below. In the diagram, we consider three timescales –
immediate, mid-term and long term – and three scales, namely, the operational, the commsioning
level and, finally, policy.
20:20 The vision in bites
1-3 years 6-7 years
10+ years
Time
Lean, processes
Patient focused
Options & possibilities
Self/enabled care
Planning- & risk-based
Mixed-economy
Flexible and adaptable
Measurement-driven
Demonstrably equity
Integrated patient life
Consistent
Managed vocation
Widespread use of
management,
planning & riskassessment methods
New skills (e.g. CoM)
Working frameworks
Bedded-in measures
Health Econ. in loop
NISE
Staff College
Evidence (e.g. studies)
Training
Pathways (tools, etc)
Frameworks
Tools
Processes
Measures
A new vision
Measures
A plan for the system
operations
commissioning
policy
Scale
Vision
Our overall vision is to mobilise the skills of the nation for a pro-active approach to high-value
integrated health provision, which is cost-effective, high-quality, and patient-centred.
Policy:
Our vision is for a science-based approach to an integrated equitable health policy. The support for
policy making being informed by physical medical and social sciences, and the values of stakeholders
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Commissioning:
Our vision is for evidence-based commissioning of integrated health service provision. The
underlying decision processes will be based within a risk management framework offering sufficient
flexibility to adapt to future changes.
Operations:
Our vision is for smart resource efficient and effective patient-focussed operational processes, with
an emphasis on proactive self-enabled health management.
The vision in different scales:
The scene 10-year out
Policy
Ten years from now we would expect policy to provide an integrated fabric of care the wraps
around the entire patient’s life, delivering the support and challenge needed at each stage
and through each exigency. We envisage policy where questions of equity are not simply
promoted or used to drive the system, but can also be demonstrated through data and, when
planning, are modelled out ahead of time.
We would hope that policy would have reached a stage of maturity where continuous
improvement would take place with a degree of consistency – and that frequent changes of
the basis and measurement of care delivery would, by then, be a thing of the past.
Finally, we envisage a time when the vocational aspirations of those choosing to devote
themselves to care delivery are respected. We look forward to a time when the systems
ensuring quality, equity and sustainability fully accommodate the judgement and decisionmaking of the individuals delivering that care.
Simulation and modelling is likely to support this through strategic models that inform plans,
assist in the selection of measure and demonstrate the benefits to individuals.
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Commissioning
In ten years’ time, care is likely to be delivered in a mixed economy, embracing what is
currently health service budges and social case budgets, but also involving significant levels
of private money, through direct payments and insurance cover. Commissioners will need
the business and economic models to operate effectively in such an environment.
Planning and risk management will be critical element of all commissioning, bedded deeply
into the mindset of those driving and responding within the cycles of procurement and
delivery.
To ensure continuous improvement and sustainability, the processes will have to be flexible
and adaptable – embracing small call-off items and regional contracts.
Finally, through appropriate interpretation of patient outcomes, the entire system will be
driven by measures that are known to reflect fairly and holistically, the performance of the
NHS as a whole.
The role of simulation and modelling in all this is likely to lie in providing a common picture
for the various stakeholders, supporting the planning process (including what-ifs and the
derivation of measures of success) and, on the part of those accepting commissions, at all
levels to understand progress and drive continuous change.
Operations
Patients should expect, in ten years, to enjoy an empowered service in which they enjoy
considerable self-determination and involvement – which will also including sharing the risk
in decisions that are made.
Through prospective models, the diagnostic and therapy-selecting discussions will be
informed by models that indicate what the possible outcomes are and what risks lie ahead.
A risk-managing (decidedly not risk-avoiding) environment is envisaged at all levels, that
makes decisions in which all stakeholders have a known and viable role.
Finally, all this will be implemented through lean (in the broadest sense) and cost-effective
processes.
The role of modelling will be to support decision-making and the dialogue between decisionmakers at all level. A second role will lie in the design, management and roll-out and
improvement of the processes.
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The scene in the mid term:
Policy
This will not happen unless training and support institutions for commissioning are established on
the national level to develop such tools, to create an appropriately trained workforce and to support
this workforce as they engage in these processes.
Commissioning
Our mid-term vision for commissioning is that commissioning groups will have the capacity and
capability to use appropriate analytical tools to plan, purchase and monitor high quality services for
their population.
Operations
Across the broad spectrum of care service provision appropriate tools are used to foster quality,
innovation, productivity and prevention in an agile healthcare system that is responsive to patients’
needs.
Academia
We have generated the evidence base that our tools and methods deliver benefits to both patients
and service providers.
We have created sponsored post-graduate degrees across the country in healthcare management,
healthcare engineering etc. with a strong element of modelling and analytics in the curriculum.
Research effort to focus in improving the way modelling studies are conducted in healthcare, e.g.,
patient outcomes to be readily incorporated in the models we develop.
The scene in the near term
Within 1 month – letter to the Times, engaging with stakeholders
We already have the tools & techniques – need to communicate them better;
Within next 12 months: Social enterprise: differentiate ourselves from Big 5 (research focus,
academic independence, emphasis on scientific evidence-based decision making); need to define our
strengths better; not in it for commercial profit but for making an impact; recognise our weaknesses
as flip sides of our strengths; needs to be sustainable (funded by Big 5? DH?)
Need more engagement from clinicians, senior NHS managers, NICE, NPSA; CQC; need marketing
input?
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Training: need to articulate resources we already have: existing taught modules on our degree
programmes; TORCH; Warwick modules – (Leading Edge) (lean); Westminster courses ; etc? Could
offer some next year at cost to NHS? Market RIGHT workbook better?
Ditto for research; articulate tools and expertise we already have; where do we find our compelling
evidence base? Small, simple, successful studies?
Need to develop identity as a group (e.g. alongside MASHNet), and work out a way of creating a
sustainable infrastructure for development. We need to project a coherent image.
Beyond 12 months:
Developing research agenda, and stakeholder engagement agenda. Identifying scope and
requirements for modelling & simulation (and hence measures and ways of evaluating the
effectiveness of M&S).
RIGHT workbook to: m.allen.1@warwick.ac.uk
Stakeholder analysis
Who needs us?
1-3 years 6-7 years
10+ years
Time
GPs & primary Med schools &
care
staff colleges
Evidence (e.g. studies)
Training
Pathways (tools, etc)
operations
Industry &
consulting
Frameworks
Tools
Processes
Measures
The Royal The public &
Colleges government
A new vision
Measures
A plan for the system
commissioning
policy
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Scale
The wider context
Government / Policy
Hospital
(acute care)
Finance /
Insurance
Residential
Home
Home
(community services,
telecare)
Nursing
Home
Primary care
Regulators
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Education /
Professional
Institutions /
Consultancy
The framework in focus:
High quality healthcare arises from the interaction of policy, commissioning and operation.
Each of these can be divided into critical actions:
Analysis & definition (POLICY)
Specification and design (COMMISIONING)
Delivery and measurement/evaluation (OPERATION)
Within each of these are iterative processes that that might be seen as a spiral (see diagram
Measurement
Analysis
Operation
Policy
Delivery
Definition
Design
Specification
Commissioning
EXEMPLAR 1: The ‘Bugger’s Muddle’ in Dementia
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The current policy in dementia care is flexible, but not sufficiently integrated.
For example, there is a clear policy on NICE guidelines on prescribing and the medical management
of dementia. Interaction with local memory clinic would be part of a recognised care pathway.
Integration with social care is currently less well specified and more subject to variation.. This leads
to difficult decision points about care provision, and how it might be paid for, all of which leads to
great anxiety on the part of patients, carers and providers. This situation is likely to be tested
further as the population ages.
We envisage a need for clear long-term planning that integrates policy, commissioning and delivery.
Options involving much greater integrated with social care. Which take account of co-morbidity.
Clear ownerships (which might be encouraged by the forthcoming change in the commissioning
processes, but which will only be successful is there is a strategic and well-managed patient-centred
and integrated process of design.
Capacity of carers to cope (financial and environmental)
Out of time (but please don’t deduct too many marks, we did loads of revision…………)
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